Skip to main content
NCBI home page
Sage Choice logoLink to Sage Choice
. 2023 Nov 9;39(7-8):1853–1876. doi: 10.1177/08862605231211924

Shame and Emotion Dysregulation as Pathways to Posttraumatic Stress Symptoms Among Women With a History of Interpersonal Trauma

Miranda Mirabile 1, Inge Gnatt 1, Jessica L Sharp 1, Jessica L Mackelprang 1,✉
PMCID: PMC10913341  PMID: 37942893

Abstract

Women who have survived interpersonal trauma are at elevated risk of developing posttraumatic stress disorder (PTSD), and potentially modifiable factors that may be targeted in treatment warrant further investigation. This study examined a pathway from interpersonal trauma to PTSD symptoms via emotion dysregulation and shame in a large non-clinical sample of women. The sample comprised 380 women, aged 18 to 59 years (M = 31.70, standard deviation = 10.06), all of whom had a history of interpersonal trauma. Participants completed the Experience of Shame Scale, the Difficulties in Emotion Regulation Scale-Short Form, and the Life Events Checklist for DSM-5. A serial and parallel process model with interpersonal trauma as a predictor of PTSD symptoms, emotional dysregulation and facets of shame as intermediary variables, was analyzed using Statistical Package for Social Sciences Statistics PROCESS Model 81with bias-corrected bootstrap tests of indirect effects. Non-interpersonal trauma was included as a covariate. Interpersonal trauma, emotion dysregulation, and characterological and bodily shame were significantly and directly associated with PTSD symptoms, together explaining 59% of the variation in PTSD symptoms. While emotion dysregulation was associated with behavioral shame, interpersonal trauma was not associated with behavioral shame, nor was behavioral shame associated with PTSD symptoms. Tests of indirect effects supported a pathway from interpersonal trauma to PTSD symptoms via emotion dysregulation and characterological and bodily shame. These findings suggest interventions that are particularly effective at reducing emotion dysregulation and characterological and bodily shame, such as compassion and acceptance-based approaches, may complement evidence-based PTSD interventions when working with women who have survived interpersonal trauma.

Keywords: interpersonal trauma, emotion dysregulation, shame, posttraumatic stress disorder, PTSD, women

Symptoms of posttraumatic stress disorder (PTSD) include hyperarousal, re-experiencing (e.g., nightmares), avoidance (e.g., distressing feelings, people, places), and persistent negative emotional states (e.g., fear, shame) or negative beliefs about oneself and others (American Psychiatric Association, 2013). Several evidence-based interventions are strongly recommended for treating PTSD, including prolonged exposure, cognitive processing therapy, and cognitive behavioral therapy (Watkins et al., 2018). However, one-third to half of adults who complete evidence-based treatments continue to experience symptoms (Watkins et al., 2018). Persistent symptoms for a large proportion of treatment completers underscores the need to investigate potentially modifiable factors that maintain symptoms and may be targeted in treatment.

PTSD develops in response to direct or indirect exposure to potentially traumatic events (e.g., disasters, combat, serious injury). However, individuals with a history of interpersonal trauma, which encompasses physical assault, sexual assault, and other unwanted sexual experiences, tend to experience worse PTSD symptomology than those who survive other types of trauma (Jaffe et al., 2019; Kimerling et al., 2018). Despite women being more likely than men to experience interpersonal trauma, to develop PTSD (2:1 ratio) and more likely to experience more severe and chronic PTSD symptoms (Kilpatrick et al., 2013; Kimerling et al., 2018; Tolin & Foa, 2008), women are underrepresented in PTSD research (Haering et al., 2022). Indeed, “Trauma research falls short of its potential to adequately consider sex and gender” (Haering et al., 2022, p. 1); gender-sensitive investigations of PTSD etiology and treatment are needed.

Investigating pathways to PTSD symptoms among women who have survived interpersonal trauma has the potential to inform precision treatment approaches and may complement evidence-based treatments. In their meta-analysis, López-Castro et al. (2019) contended that supporting trauma survivors to work toward regulating shame may attenuate cognitions and behaviors that impact treatment outcomes (e.g., self-blame, avoidant coping) and are common among interpersonal trauma survivors (Jaffe et al., 2019). The combined roles of emotion regulation and shame in the pathway from trauma exposure to PTSD symptomology has received little empirical attention. To address these gaps in the literature, we investigated this pathway among women who have survived interpersonal trauma. Although a review of trauma models is beyond the scope of this paper (see Bryant, 2019, for a review), hereafter we summarize literature documenting relationships among key variables of interest in this study.

Trauma, Emotion Dysregulation, and PTSD

Emotion regulation entails monitoring, appraising, and modulating emotional reactions (Gratz & Roemer, 2004). Difficulties with emotion regulation, also termed emotion dysregulation, may develop in response to early and chronic childhood maltreatment (Ehring & Quack, 2010) and following interpersonal trauma exposure in adulthood (Forbes et al., 2020; Pencea et al., 2020). Emotion dysregulation includes difficulties in awareness, understanding, and/or acceptance of emotions; difficulty controlling behavior during emotional distress; lack of adaptive strategies (e.g., cognitive reappraisal) for modulating emotional responses; and nonacceptance of emotional experiences and distressing situations (Gratz & Roemer, 2004). Research investigating emotion dysregulation in PTSD has suggested it may be both a risk and a maintaining factor. Indeed, several studies have reported that emotion dysregulation predicted the development, severity, and chronicity of PTSD symptoms among adults with a history of interpersonal trauma (Contractor et al., 2020; Ehring & Quack 2010; Raudales et al., 2019).

Emotion dysregulation following trauma is likely influenced by trauma type. For instance, adult community members and undergraduate students with a history of interpersonal trauma, particularly sexual or physical assault, have reported greater emotion dysregulation compared to survivors of combat exposure or non-interpersonal trauma, such as a car collision (Berfield et al., 2022; Contractor et al., 2020; Raudales et al., 2019). Other research has highlighted the importance of emotion dysregulation in PTSD more broadly. For example, Pencea et al. (2020) found that emotion dysregulation predicted the development of chronic PTSD symptoms over and above established risk factors (e.g., existing PTSD and/or depression symptoms at the time of trauma exposure, allostatic load, history of interpersonal trauma), demonstrating the importance of emotion dysregulation in developing and maintaining PTSD. Still, further investigation into the role of emotion dysregulation in the pathway from trauma exposure to PTSD among interpersonal trauma survivors is needed.

Trauma, Shame, and PTSD

Shame is a painful affective state typified by avoidance behaviors and negative self-evaluations that are global and critical (e.g., “I am a bad person”) and often attributed to actual or perceived transgressions of social and/or cultural norms (Lewis, 1971; Tracy et al., 2007). Self-blame is commonly reported by interpersonal trauma survivors (Cromer & Smyth, 2010; DePrince et al., 2011; Vidal & Petrak, 2007). Indeed, the phenomenological experience of shame following trauma may motivate survivors to withdraw and to hide perceived deficiencies (Saraiya & López-Castro, 2016). Shame has been found to mediate the relationship between post-trauma appraisals, such as self-blame (e.g., “It is my fault”), and PTSD symptom severity in studies of child sexual abuse survivors and community samples (Alix et al., 2017; Feiring et al., 2002; Uji et al., 2007), even after controlling for risk factors (e.g., number of traumas, worst trauma, time since trauma, depressive symptoms; Seah & Berle, 2022). Shame may maintain or prolong PTSD symptoms through responses such as hyperarousal and avoidance (Feiring et al., 2002; Feiring & Taska, 2005; Leonard et al., 2020; Tipsword et al., 2022) and maladaptive cognitive and behavioral strategies (Lee et al., 2001; Taylor, 2015). Interpersonal violence survivors typically report more shame than survivors of non-interpersonal trauma (Amstadter & Vernon, 2008; DePrince et al., 2011; La Bash & Papa, 2014; Seah & Berle, 2023). One study suggested that shame is more strongly related to PTSD symptoms for adults who have experienced interpersonal trauma than for those who have not (Seah & Berle, 2023).

Emotion Dysregulation, Shame, and PTSD

Shame can be a difficult emotion to regulate (e.g., Elison et al., 2014). Indeed, difficulties in emotion regulation have been associated with elevated shame in adolescents (Paulus et al., 2016; Keng et al., 2019), university students (Zarei et al., 2018), and men combat veterans (Puhalla et al., 2021a, 2021b), suggesting emotion dysregulation may be a risk-factor for elevated shame. Moreover, difficulties regulating shame following trauma may influence the development and persistence of PTSD symptoms (Taylor, 2015). However, despite documented relationships between trauma and emotion dysregulation, trauma and shame, emotion dysregulation and shame, and shame and PTSD, research investigating the interrelationships among these variables collectively is scarce, with none specifically relating to women who have survived interpersonal trauma. One study did demonstrate that shame-related trauma appraisals and emotion regulation difficulties mediated between childhood abuse and PTSD among university students (Barlow et al, 2017). Additionally, two pivotal studies by Puhalla et al. (2021a, 2021b) demonstrated the key role of shame in the relationship between emotion dysregulation and PTSD symptoms among men combat veterans.

In one study by Puhalla et al. (2021a), the interaction between emotion dysregulation and shame predicted PTSD severity, whereby shame moderated the effect for two of the six facets of emotion dysregulation. Access to emotion regulation strategies only predicted PTSD severity among those with average or lower levels of shame. The relationship between lack of emotional awareness and PTSD severity also differed based on the level of shame. In addition, Puhalla and colleagues examined associations among changes in emotion dysregulation, shame, and PTSD symptoms in response to a cognitive behavioral therapy program (Puhalla et al., 2021b). Reductions in emotion dysregulation and shame predicted decreases in PTSD symptoms, and the pathway between reduced emotion dysregulation and PTSD was fully mediated by reductions in shame. Their longitudinal design provided strong evidence of shame as a pathway by which emotion dysregulation leads to PTSD symptoms. However, they exclusively recruited treatment-seeking men veterans exposed to combat trauma. Further research is needed to examine the pathway from trauma to PTSD symptoms among women.

Multifaceted Shame

While most PTSD research has investigated shame as a unidimensional construct, shame is multifaceted, comprising phenomenologically distinct domains (Andrews et al., 2002; López-Castro et al., 2019; Wilson et al., 2006). Characterological shame (i.e., shame regarding personal habits), behavioral shame (i.e., shame regarding particular actions), and bodily shame (i.e., shame concerning physical characteristics) have shown unique associations with mental health difficulties, including anxiety and obsessive-compulsive disorders (Singh et al., 2016; Szentágotai-Tătar et al., 2020), depression (Andrews et al., 2002; Crossley & Rockett, 2005), and eating disorders (Nechita et al., 2021). Associations between emotion regulation strategies and shame facets have also been observed; for example, expressive suppression was associated with characterological, but not behavioral or bodily shame among Italian women (Velotti et al., 2017). Characterological, behavioral, and bodily shame may relate uniquely to trauma pathology. For instance, characterological shame, but not behavioral or bodily shame, was associated with PTSD symptoms in a small, treatment-seeking clinical sample (Harman & Lee, 2010). Evidence also indicates that women with a history of interpersonal trauma tend to endorse experiencing characterological and bodily shame more so than behavioral shame (Andrews, 1997; Dyer et al., 2015; Vidal & Petrak, 2007; Weaver, 2020). Nevertheless, research investigating facets of shame separately in the pathway from trauma exposure to PTSD symptomology is lacking.

Current Study

In the current study, we tested a model that integrated trauma exposure, emotion dysregulation, and shame (characterological, behavioral, bodily) to explicate the pathway by which interpersonal trauma exposure translates into PTSD symptoms among women (see Figure 1). We proposed a serial and parallel process model in which interpersonal trauma exposure positively predicts emotion dysregulation, which in turn positively predicts facets of shame and, ultimately, PTSD symptom severity. The sequencing in this model was based on research by Puhalla et al. (2021a, 2021b) that provided longitudinal evidence that changes in emotion dysregulation preceded changes in shame (Puhalla et al., 2021b). The proposed model also incorporated non-interpersonal trauma to provide a comprehensive analysis of the unique relevance of interpersonal trauma for emotional dysregulation, shame, and PTSD symptoms.

Figure 1.

Figure 1.

Open in a new tab

Conceptual model of trauma exposure, emotion dysregulation, and shame representing the proposed pathway from interpersonal trauma exposure to PTSD symptoms.

Note. PTSD = posttraumatic stress disorder.

Method

Participants and Procedure

A community and university sample completed an online cross-sectional survey (hosted on Qualtrics). Eligibility criteria included being 18 years or older, English fluency, and exposure to one or more traumatic events. Women with a history of at least one interpersonal trauma in their lifetime were included in the current study (N = 380). Participants were recruited from a university research program in Australia, via organizations (e.g., Eating Disorders Victoria) and public spaces (e.g., libraries), and social media (e.g., Reddit). The 40- to 60-minute survey collected data on sociodemographic details, mental health symptoms (e.g., PTSD, anxiety/depression, disordered eating), trauma exposure, and chronic illness. Survey completion implied consent. Procedures were approved by the Human Research Ethics Committee at Swinburne University of Technology.

Measures

Sociodemographic and Clinical Variables

Data were collected on age, gender, country of birth, education, marital status, lifetime mental health diagnoses, and chronic illness history.

Trauma Exposure

The 17-item Life Events Checklist for DSM-5 (LEC-5; Weathers, Blake, et al., 2013) assesses lifetime exposure to potentially traumatic events. Exposure to 16 potentially traumatic events (e.g., sexual assault) are assessed; item 17 asks respondents to describe unlisted traumatic events they have experienced. Responses to item 17 were recoded into existing categories by three team members (MM, IG, JLM), where appropriate. Responses that did not fit within existing categories were recoded as “other.” The LEC demonstrates reasonable test-retest reliability and strong convergence with other measures of trauma exposure (e.g., Clinician-Administered PTSD Scale; Gray et al., 2004).

Each trauma was rated as “happened to me,” “witnessed it,” “learned about it,” “part of my job,” or “does not apply.” Responses were weighted according to the proximity of each trauma, in line with Weis et al. (2022). Ratings suggest greater traumatization may occur from events experienced directly, compared to those that are less proximal. Traumatic events that were experienced personally were weighted with a factor of 3, witnessed events were weighted with a factor of 2, and events learned about or exposed to as part of a job were weighted with a factor of 1. Higher scores indicate exposure to more trauma types and with closer proximity. Consistent with Jaffe et al. (2019), items were then summed to create two trauma type variables: interpersonal trauma (i.e., physical assault, assault with a weapon, sexual assault, other unwanted/uncomfortable sexual experience; range 1–12), and non-interpersonal trauma (i.e., all other items; range 0–39), with higher scores indicating more exposure to each trauma type.

Emotion Dysregulation

The 18-item Difficulties in Emotion Regulation Scale–Short Form (DERS-SF; Kaufman et al., 2016) assesses four dimensions of emotional regulation: awareness and understanding of emotions, acceptance of emotions, ability to engage in goal-directed behavior and refrain from impulsive behavior when experiencing negative emotions, and access to emotion regulation strategies perceived as effective. Participants respond on a 5-point Likert-type scale from 1 (almost never) to 5 (almost always). Scores are summed to produce a total score (range 1–90) and six subscale scores (each comprising 3 items): nonacceptance of emotional responses, difficulty engaging in goal-directed behavior, impulse control difficulties, lack of emotional awareness, limited access to emotion regulation strategies, and lack of emotional clarity. Lack of emotional awareness subscale items are reverse-coded. The DERS-SF has excellent psychometric properties for total and subscale scores, correlates highly with the original 36-item scale (α = .79–.91), and demonstrates good reliability and validity (Kaufman et al., 2016). Internal consistency for the total score in the current study was high (α = .93).

Shame

The Experience of Shame Scale (Andrews et al., 2002) is a 25-item self-report questionnaire that measures experiential, cognitive, and behavioral facets of shame. Participants rate their feelings over the past year on a 4-point Likert-type scale from 1 (not at all) to 4 (very much). A summed total score (range 1–100) is produced, along with three subscale scores: characterological (12 items; e.g., personal habits, what sort of person you are), behavioral (9 items; e.g., shame about doing something wrong, failure), and bodily (4 items; e.g., feeling ashamed of one’s body or parts of it). Subscale scores range from 1 to 48 (characterological), 1 to 36 (behavioral), and 1 to 16 (bodily). High internal consistency was found in the original study (Andrews et al., 2002) for the subscales (α = .86–.90), with good test-retest reliability (r = .83) for the total score. Internal consistency scores for the current study were high (α = .92–.96).

PTSD Symptoms

The 20-item PTSD Checklist for DSM-5 (PCL-5; Weathers, Litz, et al., 2013) assesses PTSD symptoms according to the DSM-5. Participants indicate on a 5-point Likert-type scale the degree to which they have been bothered by symptoms in the past month from 0 (not at all) to 4 (extremely). Scores are summed to create a total score (range 0–80). A score of 31 to 33 is indicative of probable PTSD (Weathers, Litz, et al., 2013). The PCL-5 has excellent internal consistency (α = .94), test-retest reliability (r = .82), and convergent and discriminant validity (Blevins et al., 2015). Internal consistency for the current study was high (α = .96).

Data Analysis

Preliminary Analyses

The Statistical Package for Social Sciences Statistics (SPSS; Version 28) was used to screen data for pattern of missingness and statistical assumptions, to generate descriptive statistics to describe the sample and model variables, and to conduct Pearson’s correlations to examine interrelationships among key variables.

Power Analysis

A priori power analysis for the overall model was performed using G*Power 3.1 (Faul et al., 2007). A minimum sample of 92 was necessary to detect a moderate effect for a multiple regression model with five predictors (effect size = 0.15, power level = 0.8, α = .05). Fritz and MacKinnon’s (2007) approach to estimating power for bias-corrected bootstrap tests of indirect effects indicated the sample (N = 380) was adequate to detect small to moderate indirect effects (power level = 0.8).

Model Analyses

The model was tested using Model 81 of the PROCESS macro (Version 4.1) for SPSS (Hayes, 2017), with interpersonal trauma (X) as the predictor of PTSD symptom severity (Y), and emotion dysregulation (M1) and shame facets (M2,3,4) as intermediary variables. Model 81 tests the effects for a serial and parallel process model in which the direct, indirect, and serial indirect effects can be assessed for parallel intermediary variables. A nonparametric bootstrapping method with 10,000 bootstrap estimates was used to estimate the indirect effects of the predictor variable on the outcome variable through the intermediating variables, with the indirect effects considered significant if the effect confidence interval did not cross zero (Hayes, 2017; Preacher & Hayes, 2004). Non-interpersonal trauma was included as a covariate.

Results

Sample Characteristics

The sample comprised 380 women ages 18 to 59 (M = 31.70, SD = 10.06); see Supplemental Table S1. Most participants were born in Australia or New Zealand (81.8%), and many had completed post-secondary (37.9%) or tertiary (35.8%) education. Just over half reported being employed (60.0%) and in a relationship (60.9%). Over half of participants reported one or more mental health diagnoses (64.5%), including anxiety/depression (57.6%), an eating disorder (23.7%), PTSD (17.1%), or another mental health condition (11.3%). Twenty-two percent of participants reported a chronic illness. The most commonly reported interpersonal trauma was physical assault (78.4%). Sexual assault (63.9%) and “Other unwanted or uncomfortable sexual experience” (75.3%) were also common (Supplemental Table S2).

Descriptive Statistics and Correlations

Descriptive statistics, scale reliabilities, and Pearson’s correlations for key variables are presented in Table 1. On average, emotion dysregulation was moderate, and participants had moderate-to-high levels of characterological, behavioral, and bodily shame. Based on PCL-5 scores, 44.5% of participants (n = 169) met the criteria for probable PTSD (score ≥ 31). Interpersonal trauma showed weak positive correlations with all model variables.

Table 1.

Means, SD, Pearson’s Correlations, and Reliability Coefficients for Key Variables.

Variable α M a SD 1 2 3 4 5 6 7
1. Interpersonal trauma — 5.84 2.95 —
2. Non-interpersonal trauma — 8.99 5.35 .24*** —
3. Emotion dysregulation (DERS-SF) .93 44.99 14.59 .19*** −.02 —
4. Characterological shame (ESS characterological) .96 28.16 10.52 .20* −.05 .67*** —
5. Behavioral shame (ESS behavioral) .94 23.21 7.68 .13* −.04 .65*** .83*** —
6. Bodily shame (ESS bodily) .92 11.62 3.82 .19*** .01 .49*** .62*** .59*** —
7. PTSD symptoms (PCL-5 total score) .96 29.28 19.68 .36*** .04 .70*** .63*** .58*** .54*** —
Open in a new tab

Note. N = 380. LEC-5 = Life Events Checklist for Diagnostic and Statistical Manual for Mental Disorders (5th ed.; DSM-5); DERS-SF = Difficulties in Emotion Regulation Scale–Short Form; ESS = Experience of Shame Scale; PCL-5 = Posttraumatic Stress Disorder Checklist for DSM-5; PTSD = posttraumatic stress disorder; SD = standard deviation; α = Cronbach’s alpha coefficient.

a

Score ranges vary across scales and subscales and means and standard deviations should be considered with this in mind. For example, ESS subscale scores range from 1 to 48 (characterological), 1 to 36 (behavioral), and 1 to 16 (bodily; Andrews et al., 2002). Trauma subscales ranged from 1 to 12 (interpersonal; endorsement of at least one interpersonal trauma was required for study inclusion) and 0 to 39 (non-interpersonal).

*

p < .05. **p < .01. ***p < .001.

Model Analyses

The process model predicted the direct effect of interpersonal trauma on PTSD symptoms, as well as the indirect effect of interpersonal trauma on PTSD symptoms through emotion dysregulation and the three shame facets. Results of the PROCESS model 81 analyses are displayed in Figure 2 and summarized in Table 2 (direct effects) and Supplemental Table S3 (indirect effects). The overall model was significant, R = .77, F(6, 373) = 90.21, p < .001; the variables together explained 59% of the variation in PTSD symptoms. Interpersonal trauma, emotion dysregulation, and characterological shame and bodily shame were significantly and directly associated with PTSD symptoms; behavioral shame was not. Non-interpersonal trauma (covariate) was not significantly associated with PTSD symptoms at any stage of the model.

Figure 2.

Figure 2.

Open in a new tab

Serial parallel mediation model predicting PTSD symptoms from interpersonal trauma, emotion dysregulation, and facets of shame.

Note. N = 380. Standardized coefficients are displayed. Percentile bootstrap CI for standardized coefficients based on 10,000 bootstrap samples in brackets. Solid line = significant direct effect; Dotted line = not significant direct effect; dashed line = significant indirect effect; CI = confidence interval; PSTD = posttraumatic stress disorder.

**p < .01, ***p < .001.

Table 2.

Regression Model Statistics for Serial Parallel Mediation Model Predicting PSTD Symptoms from Interpersonal Trauma, Emotion Dysregulation, and Shame Facets.

Outcome R 2 Path β B SE 95% bootstrap CI a
Emotion dysregulation .04***
R = .21, F(2,377) = 8.34, p < .001
 C: Non-interpersonal trauma −.08 −.20 .14 [−0.48, 0.07]
 X: Interpersonal trauma a 1 → .21 1.04 .26 [0.54, 1.55]
Behavioral shame .42***
R = .65, F(3,376) = 91.39 p < .001
 C: Non-interpersonal trauma −.03 −.04 .06 [−0.15, 0.07]
 X: Interpersonal trauma a4 → .01 .02 .11 [−0.19, 0.23]
 M1: Emotion dysregulation d 1 → .65 .34 .02 [0.30, 0.38]
Characterological shame .46***
R = .68, F(3,376) = 105.52 p < .001
 C: Non-interpersonal trauma −.05 −.10 .08 [−0.26, 0.05]
 X: Interpersonal trauma a 2 → .09 .32 .14 [0.04, 0.61]
 M1: Emotion dysregulation d 2 → .65 .47 .03 [0.41, 0.52]
Bodily shame .25***
R = .50, F(3,376) = 42.54, p < .001
 C: Non-interpersonal trauma −.002 .002 .03 [−0.07, 0.06]
 X: Interpersonal trauma a3 → .10 .13 .07 [0.01, 0.25]
 M1: Emotion dysregulation d 3 → .47 .12 .01 [0.10, 0.15]
PTSD symptoms .59***
R = .77, F(6,373) = 90.21, p < .001
 C: Non-interpersonal trauma .01 .05 .13 [−0.20, 0.30]
 X: Interpersonal trauma c’ → .20 1.31 .24 [0.86, 1.78]
 M1: Emotion dysregulation b4 → .44 .59 .06 [0.47, 0.72]
 M2: Characterological shame b 2 → .16 .29 .12 [0.06, 0.54]
 M3: Behavioral shame b1 → .04 .11 .15 [−0.19, 0.42]
 M4: Bodily shame b 3 → .16 .84 .22 [0.40, 1.27]
Open in a new tab

Note. N = 380. CI = confidence interval; PSTD = posttraumatic stress disorder; bold = 95% CI does not include zero indicating significant coefficient.

a

Percentile bootstrap CI for unstandardized coefficients based on 10,000 bootstrap samples.

*

p < .05, **p < .01, ***p < .001.

As Figure 2 illustrates, more interpersonal trauma exposure was associated with greater emotion dysregulation. In turn, greater emotion dysregulation was associated with more characterological, behavioral, and bodily shame. While interpersonal trauma was also directly associated with characterological and bodily shame, stronger paths to these two shame facets were evident from emotion dysregulation. Greater characterological shame and bodily shame were each associated with more PTSD symptoms. In addition to these direct pathways, bootstrap tests indicated significant indirect effects from interpersonal trauma to PTSD symptoms via emotion dysregulation, as well as from interpersonal trauma to emotion dysregulation to PTSD symptoms via characterological shame and bodily shame (see Supplemental Table S3 for tests of indirect effects). Behavioral shame was positively associated with emotion dysregulation; however, it was not associated with PTSD symptoms, nor was it associated with interpersonal trauma.

Discussion

This study investigated a model that integrated trauma exposure, emotion dysregulation, and shame (i.e., characterological, behavioral, bodily) to establish the relevance of emotion dysregulation and shame in the pathway by which interpersonal trauma exposure translates into PTSD symptoms among women. In a large, non-clinical sample of women who have survived interpersonal trauma, interpersonal trauma, emotion dysregulation, and characterological shame and bodily shame were each significantly and directly associated with PTSD symptoms; behavioral shame was not associated with PTSD symptoms or interpersonal trauma. Further, we identified indirect pathways from interpersonal trauma to PTSD symptoms via emotion dysregulation and characterological and bodily shame (Figure 2). Our model explained 59% of the variation in PTSD symptoms, indicating the relevance of both emotion dysregulation and shame in the genesis of PTSD symptoms among women interpersonal trauma survivors.

Our model was consistent with Puhalla et al.’s (2021b) model, wherein shame mediated the relationship between emotion dysregulation and PTSD symptoms among men veterans. Our findings add to the literature by demonstrating this pathway in a sample of women and by identifying characterological and bodily shame, but not behavioral shame, as pivotal in this relationship. Interestingly, there was a small correlation between interpersonal trauma and behavioral shame, but this relationship was not evident in the model, with behavioral shame solely predicted by emotional dysregulation. This finding aligns with research that found that women interpersonal trauma survivors tend to endorse characterological and bodily shame more so than behavioral shame (Andrews, 1997; Dyer et al., 2015; Vidal & Petrak, 2007; Weaver, 2020). Furthermore, we advance this literature by providing evidence that characterological and bodily shame are more likely to be associated with PTSD symptoms following interpersonal trauma.

Some studies have demonstrated that guilt is a weaker predictor of PTSD than shame (Amstadter & Vernon, 2008; Badour et al., 2017; Beck et al., 2011), with guilt distinguished by its focus on evaluations of one’s actions or behavior (e.g., “I did something bad”) and motivation toward reparative actions, rather than concealment (Janoff-Bulman, 1979; Lewis, 1971; Tracy et al., 2007). Behavioral shame shares similar characteristics to guilt, and it is plausible that this shame facet is interconnected to or co-exists with post-trauma guilt (Wilson et al., 2006), which may explain the pattern of findings observed in our model. By adopting a multidimensional conceptualization of shame, this study makes a unique contribution to the literature by identifying facets of shame that are most relevant in the pathway from emotion dysregulation to PTSD symptoms among women interpersonal trauma survivors. These findings have implications for mental healthcare for trauma survivors, including identifying emotion dysregulation and characterological and bodily shame as potential intervention targets.

Consistent with evidence indicating emotion dysregulation may develop from exposure to interpersonal trauma (Ehring & Quack, 2010; Forbes et al., 2020; Pencea et al., 2020; Raudales et al., 2019), we found that more interpersonal trauma was associated with greater emotion dysregulation among women interpersonal trauma survivors. Greater difficulties in emotion regulation were also associated with more shame, consistent with prior research in diverse populations (Keng et al., 2019; Paulus et al., 2016; Puhalla et al., 2021a, Puhalla et al., 2021b; Zarei et al., 2018). Further insight is provided by our analysis of interrelationships among these variables. While interpersonal trauma was directly associated with characterological and bodily shame in our model, stronger pathways were evident from interpersonal trauma to emotion dysregulation and from emotion dysregulation to characterological and bodily shame (Figure 2), suggesting that sequencing of these variables was appropriate. Our model also identified clear indirect effects spanning from interpersonal trauma to emotion dysregulation, then via characterological shame and bodily shame to PTSD symptoms, highlighting the value of our model in establishing this pathway from interpersonal trauma to PTSD among women.

Strengths, Limitations, and Future Research Directions

To our knowledge, this is the first study to investigate a model that integrates interpersonal trauma exposure, emotion dysregulation, facets of shame, and PTSD to explicate a pathway to PTSD symptoms among women who have survived interpersonal trauma. Recruitment of a large community-based, non-clinical sample of women trauma survivors who were diverse in age strengthened the ecological validity of the model we tested. Nevertheless, diversity was limited by the recruitment of English-speaking women, most of whom were born in Australia or New Zealand. That said, studying the experiences of women born in Australia and New Zealand contributes to the literature, which is predominated by U.S.-based samples. Still, more details on ethnicity and/or culture would have been meaningful. Moreover, women with disordered eating may have been over-represented due to distributing study advertisements to organizations that provide mental healthcare to women who experience disordered eating.

Although our study included a sample of women interpersonal trauma survivors, a population known to experience greater PTSD than men (Kilpatrick et al., 2013; Kimerling et al., 2018; Tolin & Foa, 2006), several limitations should be considered. Women’s experiences of trauma are influenced by intersectional variables (e.g., gender, sexual orientation, culture, immigration status; Crenshaw, 1990), many of which were not captured in this study. Findings should be interpreted with these caveats in mind. To increase the generalizability and transferability of our model, we recommend that further research explore whether the identified pathways exist in clinical cohorts, among other genders, and across cultures.

A strength of this study was the inclusion of a more nuanced conceptualization of shame than has been used in most PTSD-related research. This enabled us to identify unique associations between characterological and bodily shame and PTSD symptoms. Given possible conceptual overlap between behavioral shame and guilt, further research to clarify how these constructs are or are not distinct may be warranted. Moreover, by incorporating interpersonal and non-interpersonal trauma exposure into a serial and parallel process model, we explicated the pathway from interpersonal trauma, independently from other types of trauma. While trauma history was assessed using a robust measure, we did not have data on when traumas were experienced. Some research has suggested that individuals who have survived early life trauma are more likely to develop emotion regulation difficulties than those who experience trauma in adulthood (Ehring & Quack, 2010). Although our model was comprehensive in that it assessed, rather than presumed (e.g., military samples), the types and nature of trauma exposure, we recommend differentiating between trauma exposure in early and later life in future research to more thoroughly investigate the role of emotion dysregulation and to inform intervention.

The cross-sectional study design precluded casual conclusions about the assumed model pathway. Nevertheless, the model sequencing was conceptually plausible and research-informed, including strong empirical evidence of shame as a pathway by which emotion dysregulation leads to PTSD symptoms, albeit in a different population (Puhalla et al., 2021b). It is possible, however, that emotion dysregulation and shame have a bi-directional relationship. The extent to which they reinforce each other is a promising avenue for future research. Our findings may inform research using longitudinal designs and non-recursive structural equation models with reciprocal causation (i.e., feedback loops; Kline, 2023) to assess more conclusively the directionality of emotional dysregulation, shame, and PTSD symptoms among trauma survivors.

Clinical Implications

Findings from this study emphasize the importance of assessing emotional dysregulation and shame in PTSD treatment, particularly among interpersonal trauma survivors who may experience more shame than survivors of non-interpersonal trauma (Amstadter & Vernon, 2008; DePrince et al., 2011; La Bash & Papa, 2014; Seah & Berle, 2023) and struggle to regulate it. When assessing shame, we recommend that clinicians and researchers adopt a multidimensional conceptualization. Findings from this study indicate that characterological and bodily shame are likely to be of greater relevance to treatment than behavioral shame. Alongside tracking PTSD symptom change, emotion dysregulation and shame may be meaningful therapeutic targets. Whether difficulties in emotion dysregulation and particular facets of shame shift with therapeutic intervention over time, and in what order, warrants further study.

Many evidence-based interventions for PTSD are cognitively based. Despite the strengths of these interventions, they tend to be less effective at targeting shame. Further study on the role of shame in PTSD treatment is needed (Saraiya & López-Castro, 2016). Given that one in three individuals who complete evidence-based PTSD treatments continue to experience symptoms (Watkins et al., 2018), investigating how interventions that target shame and emotion dysregulation might be integrated alongside evidence-based interventions for PTSD ought to be prioritized. Compassion-focused interventions have shown promise for reducing shame in PTSD (e.g., Au et al., 2017; Gilbert & Procter, 2006; Hoffart et al., 2015). These interventions have transdiagnostic applicability and are predicated on modifying dysregulated emotions with self-kindness, rather than targeting negative self-appraisals (e.g., self-criticism/blame) that are often the focus of cognitive interventions. Acceptance-based approaches may also be useful for targeting shame in the context of PTSD symptoms, as has been shown among individuals with substance use disorders (Luoma et al., 2012). These interventions might serve to break the cycle of trauma survivors self-shaming over time, which may prolong PTSD symptoms (Harman & Lee, 2010). Alongside compassion-focused and acceptance-based interventions, introducing evidence-based strategies for bolstering emotion regulation, such as those employed in dialectical behavior therapy, may be meaningful to supporting interpersonal trauma survivors.

Conclusion

Despite advances in evidence-based treatments for PTSD, more work is needed to improve client outcomes by identifying potentially modifiable therapeutic targets. The current study identifies emotional dysregulation and shame, particularly characterological and bodily shame, as potentially worthwhile intervention targets when working with women who have survived interpersonal trauma. Our findings emphasize the need to assess shame multidimensionally and indicate that interventions that are particularly effective at reducing emotion dysregulation and shame might complement existing evidence-based PTSD interventions, particularly among women who have a history of interpersonal trauma.

Supplemental Material

sj-docx-1-jiv-10.1177_08862605231211924 – Supplemental material for Shame and Emotion Dysregulation as Pathways to Posttraumatic Stress Symptoms Among Women With a History of Interpersonal Trauma
sj-docx-1-jiv-10.1177_08862605231211924.docx (42.8KB, docx)

Supplemental material, sj-docx-1-jiv-10.1177_08862605231211924 for Shame and Emotion Dysregulation as Pathways to Posttraumatic Stress Symptoms Among Women With a History of Interpersonal Trauma by Miranda Mirabile, Inge Gnatt, Jessica L. Sharp and Jessica L. Mackelprang in Journal of Interpersonal Violence

sj-docx-2-jiv-10.1177_08862605231211924 – Supplemental material for Shame and Emotion Dysregulation as Pathways to Posttraumatic Stress Symptoms Among Women With a History of Interpersonal Trauma
sj-docx-2-jiv-10.1177_08862605231211924.docx (27.3KB, docx)

Supplemental material, sj-docx-2-jiv-10.1177_08862605231211924 for Shame and Emotion Dysregulation as Pathways to Posttraumatic Stress Symptoms Among Women With a History of Interpersonal Trauma by Miranda Mirabile, Inge Gnatt, Jessica L. Sharp and Jessica L. Mackelprang in Journal of Interpersonal Violence

Acknowledgments

The authors express gratitude to the women who participated in this study for their contribution to research and to the generation of new knowledge. We also thank Ms. Bronte McLeod and Dr. Ben Williams for their thoughtful feedback on an early draft of this manuscript that Ms. Mirabile submitted as her Honours thesis at Swinburne University of Technology.

Author Biographies

Miranda Mirabile, BPsych(Hons), is a Provisional Psychologist enrolled in a Master of Professional Psychology course at La Trobe University, Melbourne, Australia. Her research interests include shame, emotion dysregulation, and posttraumatic stress disorder among women.

Inge Gnatt, BPsych(Hons), is a PhD Candidate, Provisional Psychologist, and Lecturer in Psychology at Swinburne University of Technology, Melbourne, Australia. Her research focuses primarily on investigating how to improve current treatment approaches for eating disorders and posttraumatic stress disorder.

Jessica L. Sharp, PhD, is a Lecturer in Statistics and Psychology at Swinburne University of Technology Australia. Her research in health psychology investigates the psycho-social wellbeing of at-risk populations with a focus on identifying support needs.

Jessica L. Mackelprang, PhD, is a Senior Lecturer and Clinical Psychologist at Swinburne University of Technology, Melbourne, Australia. She uses quantitative and qualitative research methods to investigate psychological and physical trauma among communities that have been marginalized. She is interested in reducing inequities in health service access and improving health outcomes among these populations.

Footnotes

The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: This study was partially funded by an Australian Government Research Training Program Scholarship awarded to Inge Gnatt.

ORCID iD: Jessica L. Mackelprang Inline graphic https://orcid.org/0000-0001-9135-7811

Supplemental Material: Supplemental material for this article is available online.

References

  1. Alix S., Cossette L., Hébert M., Cyr M., Frappier J. Y. (2017). Posttraumatic stress disorder and suicidal ideation among sexually abused adolescent girls: The mediating role of shame. Journal of Child Sexual Abuse, 26(2), 158–174. 10.1080/10538712.2017.1280577 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing. 10.1176/appi.books.9780890425596 [DOI] [Google Scholar]
  3. Amstadter A. B., Vernon L. L. (2008). Emotional reactions during and after trauma: A comparison of trauma types. Journal of Aggression, Maltreatment & Trauma, 16(4), 391–408. 10.1080/10926770802403236 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Andrews B., Hunter E. (1997). Shame, early abuse, and course of depression in a clinical sample: A preliminary study. Cognition & Emotion, 11(4), 373–381. 10.1080/026999397379845 [DOI] [Google Scholar]
  5. Andrews B., Qian M., Valentine J. D. (2002). Predicting depressive symptoms with a new measure of shame: The Experience of Shame Scale. British Journal of Clinical Psychology, 41(1), 29–42. [DOI] [PubMed] [Google Scholar]
  6. Au T. M., Sauer-Zavala S., King M. W., Petrocchi N., Barlow D. H., Litz B. T. (2017). Compassion-based therapy for trauma-related shame and posttraumatic stress: Initial evaluation using a multiple baseline design. Behavior Therapy, 48(2), 207–221. 10.1016/j.beth.2016.11.012 [DOI] [PubMed] [Google Scholar]
  7. Badour C. L., Resnick H. S., Kilpatrick D. G. (2017). Associations between specific negative emotions and DSM-5 PTSD among a national sample of interpersonal trauma survivors. Journal of Interpersonal Violence, 32(11), 1620–1641. 10.1177/0886260515589930 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Barlow M. R., Turow R. E. G., Gerhart J. (2017). Trauma appraisals, emotion regulation difficulties, and self-compassion predict posttraumatic stress symptoms following childhood abuse. Child Abuse & Neglect, 65, 37–47. 10.1016/j.chiabu.2017.01.006 [DOI] [PubMed] [Google Scholar]
  9. Beck J. G., McNiff J., Clapp J. D., Olsen S. A., Avery M. L., Hagewood J. H. (2011). Exploring negative emotion in women experiencing intimate partner violence: Shame, guilt, and PTSD. Behavior Therapy, 42(4), 740–750. 10.1016/j.beth.2011.04.001 [DOI] [PubMed] [Google Scholar]
  10. Berfield J. B., Goncharenko S., Forkus S. R., Contractor A. A., Weiss N. H. (2022). The differential relation of trauma types with negative and positive emotion dysregulation. Anxiety, Stress, & Coping, 35(4), 425–439. 10.1080/10615806.2021.1964072 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Blevins C. A., Weathers F. W., Davis M. T., Witte T. K., Domino J. L. (2015). The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and initial psychometric evaluation. Journal of Traumatic Stress, 28(6), 489–498. 10.1002/jts.22059 [DOI] [PubMed] [Google Scholar]
  12. Bryant R. A. (2019). Post-traumatic stress disorder: A state-of-the-art review of evidence and challenges. World Psychiatry, 18(3), 259–269. 10.1002/wps.20656 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Contractor A. A., Weiss N. H., Natesan Batley P., Elhai J. D. (2020). Clusters of trauma types as measured by the Life Events Checklist for DSM-5. International Journal of Stress Management, 27(4), 380–393. 10.1037/str0000179 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Crenshaw K. (1990). Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Review, 43(6), 1241–1299. [Google Scholar]
  15. Cromer L. D., Smyth J. M. (2010). Making meaning of trauma: Trauma exposure doesn’t tell the whole story. Journal of Contemporary Psychotherapy, 40(2), 65–72. http://doi.org/10.1007/s10879-009-9130-8 [Google Scholar]
  16. Crossley D., Rockett K. (2005). The experience of shame in older psychiatric patients: A preliminary enquiry. Aging & Mental Health, 9(4), 368–373. 10.1080/13607860500131252 [DOI] [PubMed] [Google Scholar]
  17. DePrince A. P., Chu A. T., Pineda A. S. (2011). Links between specific posttrauma appraisals and three forms of trauma-related distress. Psychological Trauma: Theory, Research, Practice, and Policy, 3(4), 430–441. http://doi.org/10.1037/a0021576 [Google Scholar]
  18. Dyer A. S., Feldmann R. E., Jr., Borgmann E. (2015). Body-related emotions in posttraumatic stress disorder following childhood sexual abuse. Journal of Child Sexual Abuse, 24(6), 627–640. 10.1080/10538712.2015.1057666 [DOI] [PubMed] [Google Scholar]
  19. Ehring T., Quack D. (2010). Emotion regulation difficulties in trauma survivors: The role of trauma type and PTSD symptom severity. Behavior Therapy, 41(4), 587–598. 10.1016/j.beth.2010.04.004 [DOI] [PubMed] [Google Scholar]
  20. Elison J., Garofalo C., Velotti P. (2014). Shame and aggression: Theoretical considerations. Aggression and Violent Behavior, 19(4), 447–453. 10.1016/j.avb.2014.05.002 [DOI] [Google Scholar]
  21. Faul F., Erdfelder E., Lang A. G., Buchner A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39(2), 175–191. 10.3758/bf03193146 [DOI] [PubMed] [Google Scholar]
  22. Feiring C., Taska L., Lewis M. (2002). Adjustment following sexual abuse discovery: The role of shame and attributional style. Developmental Psychology, 38(1), 79–92. 10.1037//0012-1649.38.1.79 [DOI] [PubMed] [Google Scholar]
  23. Feiring C., Taska L. S. (2005). The persistence of shame following sexual abuse: A longitudinal look at risk and recovery. Child Maltreatment, 10(4), 337–349. 10.1177/1077559505276686 [DOI] [PubMed] [Google Scholar]
  24. Forbes C. N., Tull M. T., Rapport D., Xie H., Kaminski B., Wang X. (2020). Emotion dysregulation prospectively predicts posttraumatic stress disorder symptom severity 3 months after trauma exposure. Journal of Traumatic Stress, 33(6), 1007–1016. 10.1002/jts.22551 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Fritz M. S., MacKinnon D. P. (2007). Required sample size to detect the mediated effect. Psychological Science, 18(3), 233–239. 10.1111/j.1467-9280.2007.01882.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Gilbert P., Procter S. (2006). Compassionate mind training for people with high shame and self-criticism: Overview and pilot study of a group therapy approach. Clinical Psychology & Psychotherapy, 13(6), 353–379. 10.1002/cpp.507 [DOI] [Google Scholar]
  27. Gratz K. L., Roemer L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54. 10.1007/s10862-008-9102-4 [DOI] [Google Scholar]
  28. Gray M. J., Litz B. T., Hsu J. L., Lombardo T. W. (2004). Psychometric properties of the Life Events Checklist. Assessment, 11(4), 330–341. 10.1177/107319110426995 [DOI] [PubMed] [Google Scholar]
  29. Haering S., Schulze L., Geiling A., Meyer C., Klusmann H., Schumacher S., Knaevelsrud C., Engel S. (2022). Higher risk – Less data: Challenges to sex and gender considerations in trauma research. PsyArXiv. 10.31234/osf.io/ad35g [DOI] [PubMed]
  30. Harman R., Lee D. (2010). The role of shame and self-critical thinking in the development and maintenance of current threat in post-traumatic stress disorder. Clinical Psychology & Psychotherapy, 17(1), 13–24. 10.1002/cpp.636 [DOI] [PubMed] [Google Scholar]
  31. Hayes A. F. (2017). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. Guilford Press. [Google Scholar]
  32. Hoffart A., Oktedalen T., Langkaas T. F. (2015). Self-compassion influences PTSD symptoms in the process of change in trauma-focused cognitive-behavioral therapies: A study of within-person processes. Frontiers in Psychology, 6, 1273. 10.3389/fpsyg.2015.01273 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Jaffe A., DiLillo D., Gratz K., Messman-Moore T. (2019). Risk for revictimization following interpersonal and noninterpersonal trauma: Clarifying the role of posttraumatic stress symptoms and trauma-related cognitions. Journal of Traumatic Stress, 32(1), 42–55. 10.1002/jts.22372 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Janoff-Bulman R. (1979). Characterological versus behavioral self-blame: Inquiries into depression and rape. Journal of Personality and Social Psychology, 37(10), 1798–1809. 10.1037/0022-3514.37.10.1798 [DOI] [PubMed] [Google Scholar]
  35. Kaufman E. A., Xia M., Fosco G., Yaptangco M., Skidmore C. R., Crowell S. E. (2016). The Difficulties in Emotion Regulation Scale Short Form (DERS-SF): Validation and replication in adolescent and adult samples. Journal of Psychopathology and Behavioral Assessment, 38(3), 443–455. 10.1007/s10862-015-9529-3 [DOI] [Google Scholar]
  36. Keng S. L., Noorahman N. B., Drabu S., Chu C. M. (2019). Association between betrayal trauma and non-suicidal self-injury among adolescent offenders: Shame and emotion dysregulation as mediating factors. International Journal of Forensic Mental Health, 18(4), 293–304. 10.1080/14999013.2018.1552633 [DOI] [Google Scholar]
  37. Kilpatrick D. G., Resnick H. S., Milanak M. E., Miller M. W., Keyes K. M., Friedman M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. Journal of Traumatic Stress, 26(5), 537–547. 10.1002/jts.21848 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Kimerling R., Allen M. C., Duncan L. E. (2018). Chromosomes to social contexts: Sex and gender differences in PTSD. Current Psychiatry Reports, 20(12), 114. 10.1007/s11920-018-0981-0 [DOI] [PubMed] [Google Scholar]
  39. Kline R. B. (2023). Principles and practice of structural equation modeling. Guilford Press. [Google Scholar]
  40. La Bash H., Papa A. (2014). Shame and PTSD symptoms. Psychological Trauma: Theory, Research, Practice, and Policy, 6(2), 159–166. 10.1037/a0032637 [DOI] [Google Scholar]
  41. Lee D. A., Scragg P., Turner S. (2001). The role of shame and guilt in traumatic events: A clinical model of shame-based and guilt-based PTSD. The British Journal of Medical Psychology, 74(4), 451–466. 10.1348/000711201161109 [DOI] [PubMed] [Google Scholar]
  42. Leonard K. A., Ellis R. A., Orcutt H. K. (2020). Experiential avoidance as a mediator in the relationship between shame and posttraumatic stress disorder: The effect of gender. Psychological Trauma: Theory, Research, Practice, and Policy, 12(6), 651–658. 10.1037/tra0000601 [DOI] [PubMed] [Google Scholar]
  43. Lewis H. B. (1971). Shame and guilt in neurosis. Psychoanalytic Review, 58(3), 419–438. [PubMed] [Google Scholar]
  44. López-Castro T., Saraiya T., Zumberg-Smith K., Dambreville N. (2019). Association between shame and posttraumatic stress disorder: A meta-analysis. Journal of Traumatic Stress, 32(4), 484–495. 10.1002/jts.22411 [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Luoma J. B., Kohlenberg B. S., Hayes S. C., Fletcher L. (2012). Slow and steady wins the race: A randomized clinical trial of acceptance and commitment therapy targeting shame in substance use disorders. Journal of Consulting and Clinical Psychology, 80(1), 43–53. 10.1037/a0026070 [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Nechita D. M., Bud S., David D. (2021). Shame and eating disorders symptoms: A meta-analysis. The International Journal of Eating Disorders, 54(11), 1899–1945. 10.1002/eat.23583 [DOI] [PubMed] [Google Scholar]
  47. Paulus D. J., Vanwoerden S., Norton P. J., Sharp C. (2016). Emotion dysregulation, psychological inflexibility, and shame as explanatory factors between neuroticism and depression. Journal of Affective Disorders, 190, 376–385. 10.1016/j.jad.2015.10.014 [DOI] [PubMed] [Google Scholar]
  48. Pencea I., Munoz A. P., Maples-Keller J. L., Fiorillo D., Schultebraucks K., GalatzerLevy I., Rothbaum B. O., Ressler K. J., Stevens J. S., Michopoulos V., Powers A. (2020). Emotion dysregulation is associated with increased prospective risk for chronic PTSD development. Journal of Psychiatric Research, 121, 222–228. 10.1016/j.jpsychires.2019.12.008 [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Preacher K. J., Hayes A. F. (2004). SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behavior Research Methods, Instruments, & Computers, 36, 717–731. 10.3758/BF03206553 [DOI] [PubMed] [Google Scholar]
  50. Puhalla A., Flynn A., Vaught A. (2021. a). Shame as a moderator between emotion dysregulation and posttraumatic stress disorder severity among combat veterans seeking residential treatment. Journal of Affective Disorders, 283, 236–242. 10.1016/j.jad.2021.01.079 [DOI] [PubMed] [Google Scholar]
  51. Puhalla A., Flynn A., Vaught A. (2021. b). Shame as a mediator in the association between emotion dysregulation and posttraumatic stress disorder symptom reductions among combat veterans in a residential treatment program. Journal of Traumatic Stress, 35(1), 302–307. 10.1002/jts.22721 [DOI] [PubMed] [Google Scholar]
  52. Raudales A. M., Short N. A., Schmidt N. B. (2019). Emotion dysregulation mediates the relationship between trauma type and PTSD symptoms in a diverse trauma-exposed clinical sample. Personality and Individual Differences, 139, 28–33. 10.1016/j.paid.2018.10.033 [DOI] [Google Scholar]
  53. Saraiya T., López-Castro T. (2016). Ashamed and afraid: A scoping review of the role of shame in post-traumatic stress disorder (PTSD). Journal of Clinical Medicine, 5(11), 94–116. 10.3390/jcm5110094 [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Seah R., Berle D. (2022). Shame mediates the relationship between negative trauma attributions and posttraumatic stress disorder (PTSD) symptoms in a trauma exposed sample. Clinical Psychology in Europe, 4(3), e7801. 10.32872/cpe.7801 [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Seah R., Berle D. (2023). Does exposure to interpersonal trauma influence the relationship between shame and posttraumatic stress symptoms? Journal of Aggression, Maltreatment & Trauma, 32, 1304–1320. 10.1080/10926771.2023.2170841 [DOI] [Google Scholar]
  56. Singh S., Wetterneck C. T., Williams M. T., Knott L. E. (2016). The role of shame and symptom severity on quality of life in obsessive-compulsive and related disorders. Journal of Obsessive-Compulsive and Related Disorders, 11, 49–55. 10.1016/j.jocrd.2016.08.004 [DOI] [Google Scholar]
  57. Szentágotai-Tătar A., Nechita D. M., Miu A. C. (2020). Shame in anxiety and obsessive-compulsive disorders. Current Psychiatry Reports, 22(16), 1–9. 10.1007/s11920-020-1142-9 [DOI] [PubMed] [Google Scholar]
  58. Taylor T. F. (2015). The influence of shame on posttrauma disorders: Have we failed to see the obvious? European Journal of Psychotraumatology, 6, 28847. 10.3402/ejpt.v6.28847 [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Tipsword J. M., Brown-Iannuzzi J. L., Jones A. C., Flores J., Badour C. L. (2022). Avoidance coping partially accounts for the relationship between trauma-related shame and PTSD symptoms following interpersonal trauma. Violence Against Women, 28(1), 107–125. 10.1177/1077801220988350 [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Tolin D. F., Foa E. B. (2008). Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Psychological Trauma: Theory, Research, Practice, and Policy, S(1), 37–85. 10.1037/1942-9681.S.1.37 [DOI] [PubMed]
  61. Tracy J. L., Robins R. W., Tangney J. P. (Eds.). (2007). The self-conscious emotions: Theory and research. Guilford Press. [Google Scholar]
  62. Uji M., Shikai N., Shono M., Kitamura T. (2007). Contribution of shame and attribution style in developing PTSD among Japanese university women with negative sexual experiences. Archives of Women's Mental Health, 10(3), 111–120. 10.1007/s00737-007-0177-9 [DOI] [PubMed] [Google Scholar]
  63. Velotti P., Garofalo C., Bottazzi F., Caretti V. (2017). Faces of shame: Implications for self-esteem, emotion regulation, aggression, and well-being. The Journal of Psychology, 151(2), 171–184. 10.1080/00223980.2016.1248809 [DOI] [PubMed] [Google Scholar]
  64. Vidal M. E., Petrak J. (2007). Shame and adult sexual assault: A study with a group of female survivors recruited from an East London population. Sexual and Relationship Therapy, 22(2), 159–171. 10.1080/14681990600784143 [DOI] [Google Scholar]
  65. Watkins L. E., Sprang K. R., Rothbaum B. O. (2018). Treating PTSD: A review of evidence-based psychotherapy interventions. Frontiers in Behavioral Neuroscience, 12, 258. 10.3389/fnbeh.2018.00258 [DOI] [PMC free article] [PubMed] [Google Scholar]
  66. Weathers F. W., Blake D. D., Schnurr P. P., Kaloupek D. G., Marx B. P., Keane T. M. (2013). The Life Events Checklist for DSM-5 (LEC-5) – Standard. [Measurement instrument]. https://www.ptsd.va.gov/
  67. Weathers F. W., Litz B. T., Keane T. M., Palmieri P. A., Marx B. P., Schnurr P. P. (2013). The PTSD Checklist for DSM-5 (PCL-5) – Standard [Measurement instrument]. https://www.ptsd.va.gov/
  68. Weaver T. L., Elrod N. M., Kelton K. (2020). Intimate partner violence and body shame: An examination of the associations between abuse components and body-focused processes. Violence Against Women, 26(12–13), 1538–1554. 10.1177/1077801219873434 [DOI] [PubMed] [Google Scholar]
  69. Weis C. N., Webb E. K., Stevens S. K., Larson C. L., deRoon-Cassini T. A. (2022). Scoring the Life Events Checklist: Comparison of three scoring methods. Psychological Trauma: Theory, Research, Practice, and Policy, 14(4), 714–720. 10.1037/tra0001049 [DOI] [PMC free article] [PubMed] [Google Scholar]
  70. Wilson J. P., Drozdek B., Turkovic S. (2006). Posttraumatic shame and guilt. Trauma, Violence & Abuse, 7(2), 122–141. 10.1177/1524838005285914 [DOI] [PubMed] [Google Scholar]
  71. Zarei M., Momeni F., Mohammadkhani P. (2018). The mediating role of cognitive flexibility, shame and emotion dysregulation between neuroticism and depression. Iranian Rehabilitation Journal, 16(1), 61–68. 10.29252/nrip.irj.16.1.61 [DOI] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

sj-docx-1-jiv-10.1177_08862605231211924 – Supplemental material for Shame and Emotion Dysregulation as Pathways to Posttraumatic Stress Symptoms Among Women With a History of Interpersonal Trauma
sj-docx-1-jiv-10.1177_08862605231211924.docx (42.8KB, docx)

Supplemental material, sj-docx-1-jiv-10.1177_08862605231211924 for Shame and Emotion Dysregulation as Pathways to Posttraumatic Stress Symptoms Among Women With a History of Interpersonal Trauma by Miranda Mirabile, Inge Gnatt, Jessica L. Sharp and Jessica L. Mackelprang in Journal of Interpersonal Violence

sj-docx-2-jiv-10.1177_08862605231211924 – Supplemental material for Shame and Emotion Dysregulation as Pathways to Posttraumatic Stress Symptoms Among Women With a History of Interpersonal Trauma
sj-docx-2-jiv-10.1177_08862605231211924.docx (27.3KB, docx)

Supplemental material, sj-docx-2-jiv-10.1177_08862605231211924 for Shame and Emotion Dysregulation as Pathways to Posttraumatic Stress Symptoms Among Women With a History of Interpersonal Trauma by Miranda Mirabile, Inge Gnatt, Jessica L. Sharp and Jessica L. Mackelprang in Journal of Interpersonal Violence

Articles from Journal of Interpersonal Violence are provided here courtesy of SAGE Publications

RESOURCES